Ann Thorac Surg 2007;83:2199-2201
© 2007 The Society of Thoracic Surgeons
Case Reports
Effective Approach for the Treatment of Bronchopleural Fistula: Application of Endovascular Metallic Ring-Shaped Coil in Combination With Fibrin Glue
Cumhur M. Sivrikoz, MDa,*,
Tamer Kaya, MDb,
Cumhur M. Tulay, MDa,
lknur Ak, MDc,
Ayten Bilir, MDd,
Egemen Döner, MDa
a Department of Thoracic Surgery, Eski
ehir Osmangazi University Faculty of Medicine, Osmangazi University Medical School, Eskiehir, Turkey
b Department of Radiology, Eskiehir Osmangazi University Faculty of Medicine, Osmangazi University Medical School, Eskiehir, Turkey
c Department of Nuclear Medicine, Eskiehir Osmangazi University Faculty of Medicine, Osmangazi University Medical School, Eskiehir, Turkey
d Department of Anesthesiology, Eskiehir Osmangazi University Faculty of Medicine, Osmangazi University Medical School, Eskiehir, Turkey
Accepted for publication January 8, 2007.
* Address correspondence to Dr Sivrikoz, Eskiehir Osmangazi Üniversitesi T
p Fakültesi, Gö
üs Cerrahi AD 26480, Meelik Kampusü, Eskiehir, Turkey (Email: mcumhurs{at}hotmail.com).
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Abstract
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The development of bronchopleural fistula is an important complication after pulmonary resections. Generally, conventional treatment methods are used in patients having bronchopleural fistulas. Recently, there has been an increase in the use of minimally invasive methods yielding better results. In our study, we applied a combination of endovascular metallic ring coil and fibrin glue. We hereby think that such an approach for a combination might be a contribution to improving the already existing minimally invasive treatment methods.
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Introduction
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After pneumonectomy, bronchopleural fistula is a complication very well known by thoracic surgeons with its rather resistant nature to cure. It is also known that some factors such as ischemia, infection, and long-term mechanical ventilation are negative influences contributing to the development of bronchopleural fistula [1]. Recently, there has been an increase in the use of minimally invasive methods for the treatment of bronchopleural fistulas. In our case of bronchopleural fistula, we combined endovascular ring shape metallic coil and fibrin glue in our treatment attempt.
A 59-year-old man had undergone left pneumonectomy with the diagnosis of T2N0M0 adenocarcinoma in 2000. In October 2005, the patient consulted us with symptoms of a sudden-onset cough, fever, and purulent sputum. We found a diminishment in the amount of intrathoracic fluid level on the chest radiograph (Fig 1). In the stump of the left main bronchus, a fistula of 3 mm diameter was observed by bronchoscopy. We diagnosed empyema by examining the intrathoracic fluid with biochemical and microbiological analyses. Tube thoracostomy was performed to drain the empyemic cavity, and antibiotic administration was initiated. The intrathoracic cavity was irrigated daily to control clinical stability.
The patient then underwent a rigid bronchoscopic procedure under general anesthesia. We maintained the ventilation by way of insufflations after inserting a catheter into the right main bronchus. After directing the bronchoscope to the left main bronchus, we observed the fistula. Three guidewires (0.035 inches [150 cm length], straight flexible tip fixed core guidewires; Kimal, Uxbridge, United Kingdom) were diverted to the intrathoracic cavity through the fistula. The inner sides of three 5F multipurpose vascular catheters (Cordis, Roden, Netherlands) were soaked in concentrated fibrinogen and thrombin solutions. These catheters were pushed forward toward the guiding catheters. Because three catheters could pass through the fistula, we anticipated that the diameter of the fistula was larger than 3 mm. We removed the guidewires and inserted endovascular ring–shaped metallic coils (fibered platinum coil 5 mm x 50 mm x 4 mm; Boston Scientific, Cork, Ireland) into the catheters. We soaked these coils in concentrated fibrinogen and thrombin while pushing forward toward the fistula tracts. Coils were inserted into the fistula tracts independently. Coils moistened by concentrated fibrinogen and thrombin caused a reaction with fibrin glue after being exposed to the inner side of the tract catheters. This reaction contributed to the formation of a unique shape by the coils while they moved together on the tract catheters. Under scopic guidance, we confirmed that the coils were stable, fit, and well balanced within the bronchus and the thoracic cavity. We sprayed fibrin glue solution on the endobronchial side of the fistula, which did not change the stability of the coils after the formation of this structure. Discontinuation of air leakage from the tube thoracostomy signaled the closure in the fistula tract, which was further confirmed with flexible bronchoscopy and dynamic ventilation graphy. After obtaining negative results from microbiological cultures, the cavity was filled according to the procedure of Clagett [2]. Tube thoracostomy was removed. The patient has been followed up in our clinic for the last 12 months without any recurrence of the fistula (Fig 2).
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Fig 2. Coils were placed into the fistula tract, and the cavity was filled according to the procedure of Clagett.
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Comment
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The incidence of bronchopleural fistula is 1% to 4 % after pneumonectomy and carries a high risk of mortality of about 16% to 70%. Depending on the diameter of the fistula, purulent sputum may cause a diminishment in intrapleural fluid level. Empyema and purulent sputum may also cause serious aspiration pneumonia [2]. In our case, tube thoracostomy was performed and clinical stability was achieved. The routine approach to managing fistula includes surgical treatment followed by antibiotic administration and intrathoracic irrigation [1, 2]. Some studies have been performed with the use of fibrin glue in bronchopleural fistulas without any success in fistulas larger than 2 mm. Fibrin glue was generally expectorated in these studies [3, 4]. We also think that application of fibrin glue alone could remain insufficient for large fistulas.
Watanabe and colleagues [5] have suggested coil and glue combination. In their study, coil was placed to the fistula tract, and coil was considered as a core for fibrin glue occlusion [5]. Schimizu and associates [6] performed 7 cm straight coil and fibrin glue combination on the patient’s fistula tracts after right lower lobectomy. They found that the fistula was closed successfully when this combination was powered with oxidized, regenerated cellulose [6]. Watanabe and colleagues [7] reported that more metallic coil application would be more effective in large fistulas.
Our case concerns nearly the same application type; however, it makes a contribution by extending the practice area. Shimizu and colleagues [6] applied straight type metallic coils, but we applied ring-shaped metallic coil. The fistula tract was surrounded by the coil’s curves equally and was well balanced on both endobronchial and intrathoracic sides. These curves resulted in the coil hanging more strongly on the bronchus. This stability prevented the removal of the coil and the expectoration of the fibrin glue by the patient. Metallic coil curves must be well balanced on both the endobronchial and intrathoracic sides of the fistula for the stability. If that is not the case, the coils can drop down into the thoracic cavity or can hang up in the bronchial lumen without closing the fistula.
In our experience, the inner sides of the catheters were soaked in concentrated fibrinogen and thrombin before the metallic coils were loaded. After placement, the coils reacted with each other with the help of concentrated fibrinogen and thrombin. The coils generated a core for fibrin glue occlusion and had been converted to metallic structures to enable the closure of the fistula. Fibrin glue was sprayed on this metallic body, and the fistula was closed totally. Three metallic coils were placed into the large bronchopleural fistula after pneumonectomy. Applying more than one coil to close a large fistula will be more effective. In the literature, there are successful applications such as decalcified human spongiosa and fibrin sealant combinations, metallic expandable wall stent, and Dumon stent insertions in bronchopleural fistula treatment apart from metallic coil applications [8–10]. Recently, endobronchial valve applications were reported, but these approaches do not concern the treatment of the fistula after pneumonectomy [11, 12].
Formation of bronchopleural fistulas after pulmonary resections remains a challenge for surgeons. Recently, minimally invasive procedures have been increasingly used for treatment, but it is too early to comment on the advantages and superiorities of these techniques to each other. Nevertheless, increasing the numbers in the series of minimally invasive procedures would make such comparisons possible. We think that our case provides a valuable contribution to minimally invasive solutions for the treatment of bronchopleural fistulas.
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References
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- Asamura H, Naruke T, Tsuchiya R, Goya T, Kondo H, Suemasu K. Bronchopleural fistulas associated with lung cancer operationsUnivariate and multivariate analysis of risk factors, management, and outcome. J Thorac Cardiovasc Surg 1992;104:1456-1464.[Abstract]
- Ponn RB. Complications of pulmonary resectionIn: Shields TW, Locicero III J, Ponn RB, Rusch VW, editors. General thoracic surgery. 6th ed.. Philadelphia: Lippincott Williams and Wilkins; 2005. pp. 554-586.
- Jessen C, Sharma P. Use of fibrin glue in thoracic surgery Ann Thorac Surg 1985;39:521-524.[Abstract]
- Glover W, Chavis TV, Daniel TM, Kron IL, Spotnitz WD. Fibrin glue application through the flexible fiberoptic bronhchoscope: closure of bronchopleural fistulas J Thorac Cardiovasc Surg 1987;93:470-472.[Abstract]
- Watanabe S, Sato H. Coil occlusion method for treatment of bronchial fistula J Jpn Assoc Chest Surg 1999;13:488-493.
- Shimizu J, Takizawa M, Yachi T, et al. Postoperative bronchial stump fistula responding well to occlusion with metallic coils and fibrin glue via a tracheostomy: a case report Ann Thorac Cardiovasc Surg 2005;11:104-108.[Medline]
- Watanabe S, Watanabe T, Urayama H. Endobronchial occlusion method of bronchopleural fistula with metallic coil and glue Thorac Cardiovasc Surg 2003;51:106-108.[Medline]
- Baumann WR, Ulmer JL, Ambrose PG, Garvey JM, Jones TD. Closure of a bronchopleural fistula using decalcified human spongiosa and a fibrin sealant Ann Thorac Surg 1997;64:230-233.[Abstract/Free Full Text]
- Madden PB, Sheth A, Ho TBL, McAnulty GR, Sayer RE. A novel approach to the management of persistent postpneumonectomy bronchopleural fistula Ann Thorac Surg 2005;79:2128-2130.[Abstract/Free Full Text]
- Tsukada H, Osada H. Use of a modified Dumon stent for postoperative bronchopleural fistula Ann Thorac Surg 2005;80:1928-1930.[Abstract/Free Full Text]
- Mitchell KM, Boley TM, Hazelrigg SR. Endobronchial valves for treatment of bronchopleural fistula Ann Thorac Surg 2006;81:1129-1131.[Abstract/Free Full Text]
- Snell GI, Holsworth L, Fowler S, et al. Occlusion of a broncho-cutaneous fistula with endobronchial one-way valves Ann Thorac Surg 2005;80:1930-1932.[Abstract/Free Full Text]
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Abstract
Introduction
